Does Blue Cross Blue Shield of Arizona Cover Farxiga?

How BCBSAZ Formulary Placement Affects Your Farxiga Cost

Blue Cross Blue Shield of Arizona maintains multiple formulary lists across its commercial, marketplace (ACA), and Medicare Advantage product lines. Each list assigns drugs to numbered tiers that determine the patient's out-of-pocket share. Farxiga appears on most BCBSAZ formularies, though the specific tier can shift between plan years and product types.

On a typical BCBSAZ commercial PPO or HMO plan, Farxiga is classified as a Tier 3 preferred brand medication. That designation carries a copay in the $35 to $60 range per 30-day fill. Some high-deductible health plans (HDHPs) require the member to meet the full annual deductible before the copay structure takes effect. Members enrolled in BCBSAZ Medicare Advantage plans may see Farxiga placed on Tier 4 (non-preferred brand), where cost-sharing can climb to $70 to $90 per month depending on the plan's benefit design.

The SGLT2 inhibitor class now includes several branded competitors: empagliflozin (Jardiance), ertugliflozin (Steglatro), and canagliflozin (Invokana). BCBSAZ formulary committees evaluate clinical trial data, wholesale acquisition cost, and manufacturer rebate agreements when assigning tier placement. In some plan years, Jardiance holds the preferred position over Farxiga, which can push Farxiga to a higher tier and a larger copay. Members should verify the current formulary year's tier assignment through the BCBSAZ member portal or by calling the number on the back of their insurance card.

According to the FDA-approved prescribing information for Farxiga, dapagliflozin is indicated at 10 mg once daily for type 2 diabetes, heart failure with reduced or preserved ejection fraction, and chronic kidney disease at risk of progression [1]. Coverage decisions by BCBSAZ reflect these labeled indications.

Prior Authorization Requirements for Farxiga on BCBSAZ Plans

Nearly all BCBSAZ benefit plans require prior authorization (PA) before dispensing Farxiga at the in-network copay rate. The PA process exists to confirm that the prescription aligns with FDA-labeled indications and the plan's clinical criteria.

A typical BCBSAZ PA form for Farxiga asks the prescribing clinician to document three things: the patient's confirmed diagnosis (type 2 diabetes with an HbA1c at or above 7%, NYHA Class II-IV heart failure, or eGFR-confirmed CKD), evidence that the patient has tried or has a contraindication to metformin (for the diabetes indication), and the prescriber's rationale for choosing dapagliflozin over any preferred-tier SGLT2 inhibitor on the current formulary.

PA turnaround follows Arizona Department of Insurance timelines. Standard requests receive a decision within 5 to 15 business days. Urgent requests, defined as situations where delay could seriously jeopardize the patient's health, are processed within 72 hours. If the PA is denied, the denial letter must include the specific clinical rationale and instructions for filing a first-level appeal.

For the diabetes indication specifically, the American Diabetes Association Standards of Care (2024) recommend SGLT2 inhibitors as add-on therapy for patients with type 2 diabetes who have established atherosclerotic cardiovascular disease (ASCVD), heart failure, or CKD, regardless of baseline HbA1c [2]. Citing these guidelines in the PA submission strengthens the clinical justification.

Step Therapy: Will BCBSAZ Make You Try Another Drug First?

Some BCBSAZ plans impose step therapy protocols for SGLT2 inhibitors. Step therapy means the insurance plan requires the patient to try (and fail or show intolerance to) a less expensive medication before approving a higher-tier drug.

For Farxiga prescribed for type 2 diabetes, the most common step therapy requirement is a documented trial of metformin lasting at least 90 days, with persistent HbA1c above 7% or documented GI intolerance. Some plans also require documentation that a sulfonylurea was considered and either attempted or ruled out due to hypoglycemia risk.

Step therapy generally does not apply when Farxiga is prescribed for its cardio-renal indications. The DAPA-HF trial (N=4,744) demonstrated that dapagliflozin 10 mg reduced the composite endpoint of worsening heart failure or cardiovascular death by 26% (hazard ratio 0.74; 95% CI 0.65 to 0.85; P<0.001) compared to placebo, regardless of diabetes status [3]. The DAPA-HF publication in the New England Journal of Medicine provides the primary data that most formulary committees reference when waiving step therapy for heart failure patients [3].

If your prescriber believes step therapy is clinically inappropriate for your situation, a step therapy exception request can be submitted alongside the prior authorization. Arizona insurance law permits these exceptions when the required first-line drug is likely to be ineffective, could cause an adverse reaction, or has already been tried under a prior insurance plan.

What the Major Clinical Trials Show About Farxiga

Understanding the evidence behind Farxiga helps explain why BCBSAZ covers it and why your doctor may push back against a formulary denial. Three registration-grade trials form the backbone of dapagliflozin's approval portfolio.

DECLARE-TIMI 58 enrolled 17,160 patients with type 2 diabetes who had or were at risk for ASCVD. Over a median 4.2-year follow-up, dapagliflozin 10 mg met its co-primary safety endpoint for MACE non-inferiority and reduced hospitalization for heart failure by 27% (HR 0.73; 95% CI 0.61 to 0.88) versus placebo [4]. The DECLARE-TIMI 58 results published in the New England Journal of Medicine are frequently cited in formulary review dossiers [4].

DAPA-CKD randomized 4,304 participants with CKD (eGFR 25 to 75 mL/min/1.73 m² and urinary albumin-to-creatinine ratio 200 to 5 to 000 mg/g) to dapagliflozin 10 mg or placebo. The trial was stopped early for overwhelming efficacy. Dapagliflozin reduced the primary composite of sustained eGFR decline of 50% or greater, end-stage kidney disease, or renal/cardiovascular death by 39% (HR 0.61; 95% CI 0.51 to 0.72; P<0.001) [5]. Results were published in the New England Journal of Medicine [5].

DAPA-HF, discussed above, showed a 26% reduction in the composite of cardiovascular death or worsening heart failure events across all pre-specified subgroups, including patients without diabetes [3].

The 2024 KDIGO Clinical Practice Guideline for CKD management lists SGLT2 inhibitors as a first-line recommended therapy for CKD patients with an eGFR of 20 mL/min/1.73 m² or higher [6]. This guideline designation means that BCBSAZ plans generally cannot argue that Farxiga lacks clinical support for CKD.

How to Appeal a Farxiga Coverage Denial from BCBSAZ

A denial is not the final answer. BCBSAZ members have a structured multi-level appeal process, and success rates for well-documented drug appeals are higher than many patients expect.

The first-level internal appeal must be filed within 180 calendar days of the denial notice. Your appeal packet should include a letter of medical necessity from the prescribing physician, relevant lab results (HbA1c, eGFR, UACR, NT-proBNP, or echocardiogram findings as applicable), documentation of any prior drug trials, and citations from the ADA Standards of Care or KDIGO guidelines supporting SGLT2 inhibitor use for the specific diagnosis.

BCBSAZ must issue a decision on a standard first-level appeal within 30 calendar days. For pre-service appeals (before the drug is dispensed), the timeline shortens to 15 calendar days. Expedited appeals, appropriate when delay risks serious health consequences, require a decision within 72 hours.

If the first-level appeal is denied, members can escalate to an external independent review organization (IRO). Arizona Revised Statutes Title 20, Chapter 1, Article 16 governs this process. The IRO decision is binding on the health plan. External reviews are free to the member.

The Centers for Medicare and Medicaid Services also provides oversight for BCBSAZ Medicare Advantage plan denials, and Part D members can request an independent redetermination through the Medicare appeals framework [7].

Manufacturer Savings Programs and Copay Assistance

AstraZeneca, the maker of Farxiga, offers a copay savings card that can reduce out-of-pocket costs to as little as $0 per month for commercially insured patients. The card typically covers up to $175 per 30-day prescription. Patients with government-funded insurance (Medicare Part D, Medicaid, TRICARE) are not eligible for the manufacturer copay card due to federal anti-kickback statute restrictions.

For Medicare patients facing high Part D copay obligations, several options exist. The AstraZeneca Patient Assistance Program (AZ&Me) provides free medication to patients who meet income eligibility criteria, generally those with household incomes at or below 400% of the federal poverty level. The AstraZeneca patient assistance program page on FDA.gov outlines general principles of pharmaceutical manufacturer assistance programs [8].

Pharmacy benefit manager (PBM) discount programs may also apply. If BCBSAZ contracts with a PBM such as Prime Therapeutics (its most common PBM partner), the negotiated rate for Farxiga may already reflect a significant discount off the wholesale acquisition cost of approximately $580 per month. The member's actual copay depends on the tier and the plan's cost-sharing structure after PBM contract pricing.

Farxiga vs. Jardiance: Which SGLT2 Inhibitor Does BCBSAZ Prefer?

BCBSAZ formulary committees periodically evaluate whether Farxiga (dapagliflozin) or Jardiance (empagliflozin) should hold the preferred position within the SGLT2 inhibitor class. This decision changes with contract cycles and rebate negotiations, so preferred status can shift from one plan year to the next.

Both drugs share the same FDA-approved indications for type 2 diabetes, heart failure, and CKD. Clinical outcomes data are broadly comparable. The EMPA-REG OUTCOME trial (N=7,020) showed empagliflozin reduced cardiovascular death by 38% (HR 0.62; 95% CI 0.49 to 0.77; P<0.001) in patients with type 2 diabetes and established cardiovascular disease [9]. The EMPA-REG OUTCOME publication remains the primary empagliflozin cardiovascular outcomes reference [9].

When BCBSAZ designates Jardiance as the preferred SGLT2 inhibitor, prescribers requesting Farxiga must submit a PA explaining why the non-preferred agent is medically necessary. Acceptable reasons include documented intolerance to empagliflozin (e.g., recurrent genital mycotic infections on Jardiance but not on a prior Farxiga trial), a renal indication where DAPA-CKD data apply and no comparable empagliflozin CKD trial existed at the time of the formulary decision, or a dose-specific clinical rationale (Farxiga 5 mg is approved for HF, whereas Jardiance uses 10 mg, which may matter for patients sensitive to SGLT2 inhibitor dose).

Patients who are currently stable on Farxiga and face a mid-year formulary switch to Jardiance preference should be aware of BCBSAZ's continuity-of-care provisions. Arizona insurance regulations require plans to honor an existing prescription for a transitional supply period (typically 90 days) to allow for a safe medication transition.

Understanding Your BCBSAZ Plan Type and Farxiga Access

Not all BCBSAZ plans are created equal. The plan type directly shapes formulary rules and cost-sharing.

Commercial PPO/HMO plans generally offer the most straightforward path to Farxiga coverage. These plans use a tiered formulary with predictable copays after the PA clears. Members with a PPO can fill prescriptions at any network pharmacy; HMO members may be directed to specific pharmacies.

ACA Marketplace plans sold through the federal exchange by BCBSAZ follow Essential Health Benefits (EHB) drug coverage requirements. All ACA plans must cover at least one drug per United States Pharmacopeia (USP) therapeutic class. Since SGLT2 inhibitors represent a distinct pharmacologic class, at least one SGLT2 inhibitor must appear on the formulary. If that drug is Jardiance, Farxiga may still be obtainable through an exception.

Medicare Advantage Part D plans have their own formulary and cost-sharing rules governed by CMS. BCBSAZ Medicare Advantage members should check the plan's Evidence of Coverage (EOC) document, updated annually, for Farxiga's tier placement and any coverage gap (donut hole) implications. In the coverage gap phase during 2026, Medicare Part D enrollees pay 25% coinsurance for brand-name drugs, which on Farxiga's list price could mean approximately $145 per month until reaching the catastrophic coverage threshold of $8 to 000 in true out-of-pocket spending.

Medicaid (AHCCCS) managed care plans administered by BCBSAZ cover Farxiga under the Arizona Health Care Cost Containment System preferred drug list. AHCCCS maintains its own PA criteria separate from BCBSAZ commercial policies, and copays are minimal (typically $0 to $4).

Tips for Getting Farxiga Covered on the First PA Attempt

A clean, well-documented prior authorization reduces the chance of denial and avoids delays in starting treatment.

Include the patient's current HbA1c result (dated within 90 days), documented metformin trial or contraindication, and the specific FDA-approved indication being targeted. For heart failure, attach the most recent echocardiogram showing ejection fraction. For CKD, include both eGFR and UACR values.

Reference the ADA 2024 Standards of Care pharmacologic treatment algorithm, which positions SGLT2 inhibitors as preferred second-line agents for patients with cardiorenal comorbidities [2]. Quote the specific recommendation: "For patients with type 2 diabetes and established ASCVD, heart failure, or CKD, an SGLT2 inhibitor with demonstrated benefit is recommended as part of the glucose-lowering regimen, independent of HbA1c."

Submit electronically through the BCBSAZ provider portal rather than by fax. Electronic submissions route directly to the pharmacy benefit review queue, whereas fax submissions require manual intake and can add 2 to 5 business days to processing.

A 2023 analysis published in JAMA Network Open found that 24.1% of prior authorization requests for cardiometabolic medications were initially denied, but 56% of those denials were overturned on appeal when supporting clinical documentation was included [10]. The data suggest that persistence pays: more than half of initial denials do not reflect a true coverage exclusion but rather incomplete documentation.